CMS/EIP Fiscal Report Statewide
Services beginning 10/01/2021 ending 12/31/2021 Date of Report:02/04/2022 Page: 1
List order: No List
Payclass Filters:MED
Bill Flag Filter:RBPU
Eligibility Filter:All
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
TCM-T1017TL-TARGETED CASE MANAGEMENT 10106 33427.25000 1236181.2500 36.9812
Subtotal (Total Children Is Unduplicated) 10106 33427.25000 1236181.2500 36.9812
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 13 25.500000 1912.5000 75.0000
IPDEF-T1024GNTSGT-F/U PHYC AND DEV EVAL BY SPAT 48 85.000000 6336.0000 74.5412
IPDEF-T1024GOTS-F/U PSYCH AND DEV EVAL BY OT 7 13.000000 975.0000 75.0000
IPDEF-T1024GOTSGT-F/U PHYC AND DEV EVAL BY OT 28 47.000000 3525.0000 75.0000
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 6 11.500000 862.5000 75.0000
IPDEF-T1024GPTSGT-F/U PHYC AND DEV EVAL BY PT 11 18.000000 1350.0000 75.0000
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 6 12.000000 900.0000 75.0000
IPDEF-T1024TLTSGT-F/U PHYC AND DEV EVAL BY EI PROF 14 23.500000 1733.2500 73.7553
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 22 41.500000 2303.2500 55.5000
IPDEF-T1024TSGT-F/U PHYC AND DEV EVAL BY ITDS 46 82.500000 4578.7500 55.5000
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 288 544.000000 40800.0000 75.0000
IPDEI-T1024GNUKGT-INITIAL PSYCH AND DEV EVAL BY SPAT 645 1133.500000 84915.0000 74.9140
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 85 157.000000 11775.0000 75.0000
IPDEI-T1024GOUKGT-INITIAL PSYCH AND DEV EVAL BY OT 321 490.500000 36787.5000 75.0000
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 118 216.500000 16237.5000 75.0000
IPDEI-T1024GPUKGT-INITIAL PSYCH AND DEV EVAL BY PT 139 234.000000 17550.0000 75.0000
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 338 648.500000 35991.7500 55.5000
IPDEI-T1024HNUKGT-INITIAL PSYCH AND DEV EVAL BY ITDS 798 1348.500000 74841.7500 55.5000
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 137 245.500000 18412.5000 75.0000
IPDEI-T1024TLGT-INITIAL PSYCH AND DEV EVAL BY EI PROF 243 414.000000 31001.2500 74.8822
OCTH-97165TL-OT EVAL LOW COMPLEXITY 2 2.000000 102.1000 51.0500
OCTH-97165TLGT-OT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
OCTH-97166TLGT-OT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
PSTF-97164-PT RE-EVAL EST PLAN CARE 1 1.000000 51.0500 51.0500
PSTH-97161-PT EVAL LOW COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162-PT EVAL MODERATE COMPLEXITY 1 1.000000 51.0500 51.0500
PSTH-97162TL-PT EVAL MODERATE COMPLEXITY 2 2.000000 102.1000 51.0500
SCREEN-T1023-SCREENING 19 19.000000 950.0000 50.0000
SPCH-92523-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 4 4.000000 204.2000 51.0500
SPCH-92523GT-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 1 1.000000 51.0500 51.0500
SPCH-92523TL-EVAL OF SPCH SOUND PROD; EVAL LANG COMP 9 9.000000 459.4500 51.0500
SPCH-92523TLGT-EVAL OF SPCH SOUND PROD; EVAL LANG COM 3 3.000000 146.6500 48.8833
SPCH-92610-EVAL OF ORAL,PHARYNGEAL SWALLOWING FUNC 1 1.000000 44.5500 44.5500
Subtotal (Total Children Is Unduplicated) 1932 5838.500000 395154.9000 67.6809
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EI Services,Class #03
EIIF-T1027SC-EI INDIVIDUAL SESSION BY EI PROF 191 796.250000 39812.5000 50.0000
EIIF-T1027SCGT-EI INDIVIDUAL SESSION BY EI PROF 347 1055.250000 52762.5000 50.0000
OCCT-97530-OT SESSION BY LICENSED OT 12 24.000000 1714.5600 71.4400
OCCT-97530GT-OT SESSION BY LICENSED OT 11 15.250000 1089.4600 71.4400
OCCT-97530TL-OT SESSION BY LICENSED OT 27 66.500000 4750.7600 71.4400
OCCT-97530TLGT-OT SESSION BY LICENSED OT 78 231.250000 16520.5000 71.4400
PHY-97110-PT SESSION BY LICENSED PT 16 48.500000 3464.8400 71.4400
PHY-97110GT-PT SESSION BY LICENSED PT 5 11.000000 785.8400 71.4400
PHY-97110TL-PT SESSION BY LICENSED PT 47 157.250000 11233.9400 71.4400
PHY-97110TLGT-PT SESSION BY LICENSED PT 46 137.000000 9787.2800 71.4400
SPL-92507-SPL THERAPY SESSION BY LICENSED SLP 33 70.500000 5036.5200 71.4400
SPL-92507GT-SPL THERAPY SESSION BY LICENSED SLP 8 12.000000 857.2800 71.4400
SPL-92507TL-SPL THERAPY SESSION BY LICENSED SLP 78 292.250000 20878.3400 71.4400
SPL-92507TLGT-SPL THERAPY SESSION BY LICENSED SLP 100 420.250000 29907.5400 71.1661
SPL-92508TLGT-SPL THERAPY SESSION BY LICENSED SLP 1 1.000000 13.8800 13.8800
Subtotal (Total Children Is Unduplicated) 843 3338.250000 198615.7400 59.4970
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Total 42604.000000 1829951.8900 42.9526
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Number of Children (Unduplicated) With at Least One Service 10391
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Center 01
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1 0.500000 18.5000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1 0.500000 18.5000 0.0000
Center 03
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 68 37.000000 1369.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 1864 1806.000000 91634.4000 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 1932 1843.000000 93003.4000 0.0000
Center 04
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 13 24.500000 906.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 2792 4585.000000 183114.2500 0.0000
P 828 1362.000000 54568.8400 53062.4600
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3633 5971.500000 238589.5900 53062.4600
Center 05
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 11 9.000000 333.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 2545 1735.250000 64204.2500 27088.6300
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2556 1744.250000 64537.2500 27088.6300
Center 07
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 12 11.500000 538.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 399 336.250000 13382.2500 0.0000
P 2713 2369.250000 101720.2500 101452.2500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3124 2717.000000 115641.0000 101452.2500
Center 09
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 377 415.250000 16967.8200 166.5000
P 3905 4116.750000 163448.8700 163655.3720
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 4282 4532.000000 180416.6900 163821.8720
Center 10
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 74 56.250000 2081.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 9029 7875.750000 327143.5000 0.0000
P 77 111.750000 6671.0100 1672.4000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 9180 8043.750000 335895.7600 1672.4000
Center 51
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 28 35.500000 2438.2500 0.0000
P 0 0.000000 0.0000 0.0000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 28 35.500000 2438.2500 0.0000
Center 52
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 0 0.000000 0.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 628 657.500000 29680.9700 252.1000
P 1866 2077.000000 97886.1500 102757.2300
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 2494 2734.500000 127567.1200 103009.3300
Center 53
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 34 31.750000 1588.0300 0.0000
U 0 0.000000 0.0000 0.0000
B 2051 1892.500000 93358.4400 1055.0000
P 1440 1401.500000 66480.6400 66462.1400
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3525 3325.750000 161427.1100 67517.1400
Center 54
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 3 4.250000 157.2500 0.0000
U 0 0.000000 0.0000 0.0000
B 3476 3012.750000 138675.9500 2109.2500
P 1753 1578.500000 73434.5600 73315.5900
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 5232 4595.500000 212267.7600 75424.8400
Center 55
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 2.000000 150.0000 0.0000
U 0 0.000000 0.0000 0.0000
B 3206 2777.000000 118754.9600 0.0000
P 4 7.750000 286.7500 286.7500
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3211 2786.750000 119191.7100 286.7500
Center 57
Flag Claims Units Chgs Paid
---------------------------------------------------------
R 1 0.500000 18.5000 0.0000
U 0 0.000000 0.0000 0.0000
B 780 1051.750000 45074.2500 0.0000
P 2303 3221.750000 133865.0000 133982.9000
D 0 0.000000 0.0000 0.0000
S 0 0.000000 0.0000 0.0000
H 0 0.000000 0.0000 0.0000
T 0 0.000000 0.0000 0.0000
0 0.000000 0.0000 0.0000
Other 0 0.000000 0.0000 0.0000
---------------------------------------------------------
Total 3084 4274.000000 178957.7500 133982.9000